The Centers for Disease Control and Prevention (CDC) recently published new recommendations on screening for hepatitis B infection.1 They recommend screening all adults (ages 18 years and older) at least once.
These recommendations differ in a few ways from those of the US Preventive Services Task Force (USPSTF).2 This Practice Alert will highlight these differences but also point out areas of agreement between the 2 sets of recommendations—and discuss why 2 separate agencies in the US Department of Health and Human Services reached different conclusions on some issues.
First, some background on hepatitis B
An estimated 580,000 to 2.4 million people in the United States have chronic hepatitis B (CHB) infection—and as many as two-thirds are unaware of it.3 In 2020, the Department of Health and Human Services published the Viral Hepatitis National Strategic Plan for the United States with a stated goal of increasing awareness of infection status among those with hepatitis B virus (HBV) from 32% to 90% by 2030.4 People living in the United States but born outside the country are at highest risk for CHB; they account for 69% of those with the infection.5
The incidence of acute HBV infection has declined markedly since the HBV vaccine was recommended for high-risk adults in 1982 and universally for infants in 1991.6,7 Overall rates of HBV infection declined fairly steadily starting around 1987—but in 2014, rates began to increase, especially in those ages 40 to 59 years.8,9 In 2019, 3192 cases were reported; but when one factors in underreporting, the CDC estimates that the number is likely closer to 20,700.10 This uptick is one reason the Advisory Committee on Immunization Practices changed its HBV vaccination recommendation for adults from a risk-based to a universal recommendation for all unvaccinated adults through age 60 years.10
Chronic hepatitis B infection has serious consequences
The proportion of those infected with HBV who develop CHB differs by age at infection: 80% to 90% if infected during infancy, 30% if infected before age 6 years, and 1% to 12% if infected as an older child or adult.8
CHB infection can lead to chronic liver disease, including cirrhosis of the liver, liver cancer, and liver failure. About 25% of those who develop CHB infection during childhood and 15% of those who develop chronic infection after childhood will die prematurely from cirrhosis or liver cancer.8
The American Association for the Study of Liver Diseases (AASLD) classifies CHB into 4 phases that reflect the rate of viral replication and the patient’s immune response.11 These phases are:
- immune-tolerant (minimal inflammation and fibrosis)
- hepatitis B e-antigen (HBeAg)-positive immune-active (moderate-to-severe inflammation or fibrosis)
- inactive CHB (minimal necroinflammation but variable fibrosis), and
- HBeAg-negative immune reactivation (moderate-to-severe inflammation or fibrosis).11
Continue to: The progression from one phase...